Wellness Community Agreement

Students who have requested to live in the Wellness Community should complete the form below. Completion of the online form does not guarantee assignment to the Wellness Community, as assignments will still be made based on application received date. However, an assignment to the Wellness Community will not be made for students who do not complete the form below.

Name:

Date of Birth:

Phone Number:

Email Address:

Permanent Address:

Why would you like to live in the Wellness Community?

I will actively support the development of a wellness community by becoming involved in activities on the floor and contributing to the welfare of the community. (Type initials to show agreement.)

I will not consume or be in the possession of alcohol, any controlled substance, or tobacco both on and off campus. (Initial.)

My guests will not possess, consume, or be under the influence of alcohol, any controlled substance, or tobacco while on the floor. (Initial.)

I will attend a community retreat the weekend August 28-29,2015 (cost covered by the Department of Residence Life). If there is a conflict with this weekend, or if special dietary needs are necessary, please contact Carol Jergenson carol.jergenson@ndsu.edu or 701.231.5603. (Initial.)

I will support other floor members in their attempt to live a healthy well-balanced life. (Initial.)

I will live a healthy life centered on wellness concepts by making lifestyle choices that maximize good health. (Initial.)

I understand that this is a lifestyle choice I am making while I live on the floor, and that failure to comply with the terms of the agreement above will result in my dismissal from the Wellness Floor and reassignment to another location. (Initial.)